Information

  • Client / Site

  • Location
  • Conducted on

  • Prepared by

  • CV-ZH-FM010-WA

PERSONNEL CONTACTED

  • 1. Worker observed during field observation

  • Worker's Name:

  • Position

  • Pre-Start & AOD

  • STAR for current task

  • SWMS reviewed and signed

  • ATWP signed

  • Online Induction completed

  • Site Induction completed

  • Competency (Operator licence, Qualification)

  • VOC completed

  • 2. Worker observed during field observation

  • Worker's Name:

  • Position

  • Pre-Start & AOD

  • STAR for current task

  • SWMS reviewed and signed

  • ATWP signed

  • Online Induction completed

  • Site Induction completed

  • Competency (Operator licence, Qualification)

  • VOC completed

  • 3. Worker observed during field observation

  • Worker's Name:

  • Position

  • Pre-Start & AOD

  • STAR for current task

  • SWMS reviewed and signed

  • ATWP signed

  • Online Induction completed

  • Site Induction completed

  • Competency (Operator licence, Qualification)

  • VOC completed

  • 4. Worker observed during field observation

  • Worker's Name:

  • Position

  • Pre-Start & AOD

  • STAR for current task

  • SWMS reviewed and signed

  • ATWP signed

  • Online Induction completed

  • Site Induction completed

  • Competency (Operator licence, Qualification)

  • VOC completed

  • 5. Worker observed during field observation

  • Worker's Name:

  • Position

  • Pre-Start & AOD

  • STAR for current task

  • SWMS reviewed and signed

  • ATWP signed

  • Online Induction completed

  • Site Induction completed

  • Competency (Operator licence, Qualification)

  • VOC completed

SAFE BEHAVIOURAL OBSERVATIONS & UNSAFE CONDITIONS

  • 1. BEHAVIOUR (Choose one)

  • Details:

  • COMMENTS

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

  • 2. BEHAVIOUR (Choose one)

  • Details:

  • COMMENTS

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

  • 3. BEHAVIOUR (Choose one)

  • Details:

  • COMMENTS

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

  • 4. BEHAVIOUR (Choose one)

  • Details:

  • COMMENTS

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

  • 5. BEHAVIOUR (Choose one)

  • Details:

  • COMMENTS

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

EQUIPMENT

  • 1. Equipment Type & Identification:

  • Plant Risk Assessment

  • Test & Tag / Maintenance in date:

  • Pre-Start completed?

  • 2. Equipment Type & Identification:

  • Plant Risk Assessment

  • Test & Tag / Maintenance in date:

  • Pre-Start completed?

  • 3. Equipment Type & Identification:

  • Plant Risk Assessment

  • Test & Tag / Maintenance in date:

  • Pre-Start completed?

HAZARDOUS SUBSTANCE REVIEW

  • 1. Product Name:

  • Identified Hazards of product:

  • SDS available

  • Product on SDS Register

  • Correct PPE available & worn by Worker

  • 2. Product Name:

  • Identified Hazards of product:

  • SDS available

  • Product on SDS Register

  • Correct PPE available & worn by Worker

  • 3. Product Name:

  • Identified Hazards of product:

  • SDS available

  • Product on SDS Register

  • Correct PPE available & worn by Worker

ASSESS THE RISK

  • What would a reasonably foreseeable outcome be if an incident occurred?

  • Consequence

  • Likelyhood

  • Risk Rating

CONTROL THE RISK

  • Was the risk controlled?

  • undefined

  • Action taken / Lessons Learned

OBSERVER'S DETAILS

  • Name of person reporting this event:

  • Enter Position

  • Enter names of personnel contacted during this activity

  • Please complete section below and highlight any additional observations and actions

  • Please add photo if required

  • Please sketch diagram if required

APPROVAL / MANAGEMENT REVIEW

  • Manager to review & approve, or send for further investigation:

  • Additional actions and Learnings shared

  • Management Approval:

  • Distribution: (1) Project Manager (2) ZH Administrator (3) Zero Harm Advisor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.